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| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
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| STATE OF OREGON |    |   |    | ) |   |  
CAPACITY CLAIMED BY SIGNER Though
statute does not require the Notary to fill in the data below, doing so may prove invaluable
to persons relying on the document. |
|   |    |  |    | ) ss. |   |
| COUNTY OF               
                   |    |  |    | ) |   |
|  |  |
| On
            , 2011, before me,
                                         
                                         
                                  ,
personally appeared
                                         
               , |   | ¨ Individual
¨ Corporate Officer(s) |
|     ¨ |   |   personally
known to me |   |                  
                                         
                     |
|   |   | **-or-** |   | ¨ Partner(s) |   | ¨ Limited
 ¨ General |
|     ¨ |   | proved to me on the basis of satisfactory evidence |   |   |
|   |   |  |   | to be the person(s) whose name(s) is/are subscribed to the within instrument and